Analysis Overview of Labrador Labrador's area measures over 265000 square kilometres, with a coastline of almost 8000kilometres of innumerable inlets, bays, and off-lying islands. Along the Labrador coast, the rugged topography of the coastline and unpredictable weather conditions can pose a risk to navigation. The environment, in terms of tide and current, wave height, wind, weather, pack ice conditions, icebergs and icing, is generally harsher and more severe than any other coast in Canada. Further, extremely rough and unpredictable depths of water occur along the Labrador coast. Many of these conditions are well known to local mariners and fishers. There is, however, a large fishery characterized by migratory fishers, in addition to a growing number of commercial mariners, who may not be familiar with the conditions or hazards. Marine cargo activity is the lifeline of Labrador due to its isolation and limited land-based transportation network. Over half of the cargo currently shipped to Labrador is in the form of dangerous goods, most of which are shipped to Goose Bay. Given that the area is ecologically sensitive, it is essential that the level of services provided for vessel navigation, be it by way of combination of the scale of navigation chart, fixed, floating, and electronic aids, be such that vessels can safely transit the area. Navigation through Narrow Channels Reportedly, the vessel's course had been gradually altered when the vessel was 5.5 cables from Rain Islet and buoy NP5 was abeam. For the vessel to have run aground, the vessel had to have been south of the recommended track and less than 2.2cables from the buoy. The optimal position of the buoy was some 160m further east of the actual position. As the vessel's position was altered when the bow came abeam of buoy NP5, the optimal positioning of the buoy would have permitted the vessel to better negotiate the turn with a greater chance of success. Good seamanship practices dictate that mariners use more than one method for position fixing as well as use all other navigation cues/information to safely navigate the vessel. The chart scale for the 300m-wide Bridges Passage was such that it reduced the bridge team's ability to accurately plot and closely monitor the vessel's progress. On the other hand, the navigational practices used aboard the Mokami further hampered the bridge team's ability to successfully negotiate the Bridges Passage. These included the following: the vessel was off the recommended track; the buoy NP5 was on the advertised position which was not the optimal position; the vessel was to the south and west of the alter course position and that initiating the turn when the bow of the vessel was in line with the buoy would result in premature course alteration; the vessel was off the recommended track; the buoy NP5 was on the advertised position which was not the optimal position; the vessel was to the south and west of the alter course position and that initiating the turn when the bow of the vessel was in line with the buoy would result in premature course alteration; This would indicate that the parallel indexing technique was not used effectively by the OOW. The visual cues used by the master were such that he did not recognize that the vessel was off the recommended track. As positions were not plotted on the chart, the use of GPS to monitor the vessel's progress would have been difficult. The GPS was not set to the appropriate chart datum and the position obtained therefrom would have been inaccurate. The error in setting would have placed the vessel further north of her actual position and close to the recommended track. This could account for the vessel being south of the recommended track, resulting in a premature course alteration. The navigation team relied on buoy NP 5, which was on its advertised position, 160 m west of the optimal position established in 1997. The team relied on the buoy to alter the vessel's course to the exclusion of other visual/ electronic cues, in spite of various navigational publications warning mariners that buoys can be out of position and that caution should be exercised in using buoys as an aid to navigation.11 Lack of Bridge Resource Management Training Close monitoring of a vessel's movement is critical for navigating safely in confined waters. Time is of the essence when initiating and executing manoeuvres. Therefore, it is essential that each bridge team member fully understands his/her role and ensures that any information that can favourably or adversely affect vessel navigation be communicated to the person in charge of pilotage/navigation. The non-implementation of bridge resource management (BRM) precepts, such as the lack of effective communication or exchange of information, has been identified as a contributing factor in a number of occurrences.12 Concerned that lack of BRM training among ships' officers increases the probability of accidents in confined Canadian pilotage waters, the Board recommended to Transport Canada (TC) that BRM training be made a pre-requisite to the issuance of new competency certificates as well as to that of continued proficiency certificates.13 In response to this recommendation, Transport Canada Marine Safety (TCMS), in consultation with industry representatives, has finalized the BRM training syllabus. Some Canadian marine training institutions now offer this training program. Currently, there is no plan to make this course mandatory. However, TCMS encourages shipping companies to take the initiative in implementing BRM concepts on their vessels. As no passage plan had been discussed and/or prepared for the transit, members of the bridge team were not fully cognisant of the OOW's planned approach, resulting in the members of the bridge team working in isolation. There were three bridge team members but only the OOW was involved in navigation. Communication was informal and input from the bridge team members respecting navigation of the vessel was minimal. Consequently, none of the bridge team members was aware that the vessel was not optimally positioned for course alteration to be successfully executed, nor were discrepancies in position communicated to team members. all of the information that could affect the navigation of the vessel, be it favourable or adverse, was not shared with the team members; effective use was not made of all available resources such as visual cue, radar and the GPS to safely complete the navigation; and each member of the bridge team did not do everything feasible to support the OOW to maximize his situational awareness. In doing so, BRM principles were not implemented effectively. Further, as the crew had not received BRM training, each member of the bridge team acted in isolation, leaving the OOW to rely solely on his performance, foregoing the potential for team work and leaving no room for error. Company' s Operational Practices and Safety Management System Safe operation of the vessel, the safety of the crew and personnel, and the safety of the environment is dependant upon close co-operation and a working relationship between shipboard and owner's shore-based personnel. An effective safety management system (SMS) addresses the issue of commitment from senior officials (both ashore and onboard), competence, attitudes and motivation of individuals at all levels.14 Although tankers pose a greater risk to the environment than most other vessels, and an accident involving the tanker can have a catastrophic impact on the economy of the region, non-convention tankers operating locally within Canadian waters are not required to have any form of safety management system, be it the International Safety Management Code or otherwise. The need for non-convention ships including tankers to have a formal SMS in place has been recognized by a number of Canadian owners/ operators of fleets who have voluntarily implemented such a system. In the absence of any form of SMS, the company and the ship's complement were operating in isolation without the benefit of a coordinated and structured approach to enhance operational safety. A compromise to safety is reflected in the following: The extent of involvement and guidance provided by the company's shore-personnel would indicate that the operational needs of the vessel were not fully recognized. The company's policy with respect to crew training lacked specifics. The selection criteria for the crew was limited to the Transport Canada mandatory certification requirements. The crew was unfamiliar with the optimum use of some of the navigation equipment and were not trained in its operation. This deprived them of the benefit that could be derived from the shipboard navigation equipment. As the bridge team members had not received BRM training, they operated in isolation. This effectively negated the benefits of team work and converted it to a single-person operation that is more prone to failure than is team work. As safety bulletins issued by the company were sparse and as TC Ship Safety Bulletins were not dispatched to the vessel, it deprived the ship's complement of information essential to safe operation. Buoy Tending Related Issues Buoy Data Record In keeping pace with changes in technology, the Canadian Hydrographic Service (CHS) charts are being updated to North American Datum 1983 (NAD83) to facilitate the use of modern electronic navigation aids. Meanwhile several charts with old datum, particularly in the Labrador region, are in use. While chart datum information is recorded on buoy data cards, the datum selected on the GPS to obtain the position is not always recorded on board Canadian Coast Guard (CCG) vessels nor is there a mandatory field for such an entry. In the event that the datum used to obtain the GPS position is at variance with the chart datum, the information as recorded on the data cards would be incomplete. This has the potential to culminate in an error in positioning the buoy as well as information as recorded in the Systme d'information de positionnement des aides (SIPA) database as in this instance. Hence, it is essential that data entry in the SIPA database be verified to ensure completeness, accuracy and integrity of the system. This was not done. Systme d'information de positionnement des aides and Safety SIPA is an electronic database containing the particulars of every buoy maintained by CCG including its mooring, characteristics, advertised position and fixing data. The policy places the responsibility on the regional CCG Marine Navigation System (MNS) program officer to maintain the integrity of the database. Although buoy NP5 had been placed in a less-than-optimal position for a period of time and the position of the buoy reported by aids tenders was different, the reason for the variation in the position was not investigated. The CCG Marine Aids Administrative Directive stipulates principles, responsibilities, and procedures involved in the service checking of marine aids to navigation. The policy is intended to assure the quality and the level of its service to further safety of vessels transiting Canadian waters. Nevertheless, some of the safety-related shortcomings identified included: data card positions (advertised positions) had been modified to reflect DGPS data gathered by ships instead of charted positions; and modifications of sextant angles and true bearings to reflect readings on buoy service reports (sometimes based on lifts). Accuracy of recorded data for positioning floating aids is essential for the integrity of the system. Given the advancement in technology, it is possible for the system to have a means to automatically compare the new entry against past recorded data and highlight changes for further investigation. In some regions, a graphical electronic or a digital method of verifying buoy positions is used to confirm the values of navaids prior to the buoy's entry in the SIPA database. In the Newfoundland region, data input in SIPA is not always verified nor is a graphical/digital system used. Integrity of SIPA System To ensure quality of service, CCG has documentation in place respecting policies and procedures regarding buoy tending operations.15 Part of the quality control measures included verification and signing off of SIPA data sheets by MNS. However, the data incorporated in the SIPA was not verified. Further, the concerns raised by the fleet personnel that the SIPA data contained errors, deletions, and unverified data essentially remained unaddressed. As the scope of these errors became more apparent, reliance on the information contained in the SIPA data sheets decreased and reliance on the unverified information contained in the buoy service reports aboard vessels increased. This effectively transformed the buoy service reports as a de facto primary source for laying buoys contrary to the established standards and without a central coordinating approach. This rendered the quality control measures ineffective and permitted an error in the data to remain unnoticed for an extended period of time. In aids tending operation, an early identification of transcription or positioning discrepancies is essential to the integrity of the system and to foster the safe navigation of vessels operating in the coastal waters. Success of such a system is dependent upon the close cooperation and good working relationship between shipboard and shore-based personnel as well as prompt and effective action to address errors. While the system has checks and balances in place - such as signing off of SIPA sheets following data verification - to help ensure the integrity of the data, it was not effectively implemented. In so doing, the system was rendered ineffective, culminating in the shipboard and shore-based personnel operating in isolation to the detriment of the system and safety. Notices to Mariners In reference to SIPA data sheets, the Aids Checking Standard states, ... data contained on this card is the authoritative reference from which information from other official publications (e.g., List of Lights, Notices to Mariners) are taken. The tombstone or advertised position is the data used to generate Notice to Mariners. To generate a Notice to Mariners, CHS is required to verify that the data on the draft notice matches the data contained in the SIPA database. Personnel in the Chart Maintenance Section at the CHS have read-only access to SIPA. There was a number of discrepancies existing between the draft notices and the SIPA data sheet: the advertised position for the buoy in the SIPA database still referenced a cancelled CHS chart and differed from the position in the draft notices; the position in the SIPA database was entered in a non-standard format; and the draft notice indicated that the buoy was a conical or starboard hand buoy contrary to the colour and number. On 15 April 1999, CHS contacted the MNS program office in St. John's to verify the accuracy of this data. The MNS officer indicated that the buoy was in the appropriate position. To verify the position of a buoy, its position is manually plotted on the appropriate chart. As outdated charts are retained by the CCG office for reference purposes, it is probable that the position of the buoy was plotted on cancelled chart No4748 with an orphan datum. The resulting position would differ from the optimal position when referenced on chart No5052 with NAD83. Consequently, the advertised position for the buoy in Notices to Mariners and the List of Lights differed from the optimal position established in 1997. Under the existing system, the CHS database accepted any information from the SIPA and had no means of verifying the status of the chart or the datum in use. Consequently, the discrepancy from the SIPA data which used the orphan datum from chart No4748 was carried forward to Notices to Mariners which referred to the new chart No5052 with NAD83. CCG - Buoy Positioning and Safety Navigational aids, be they fixed, floating, or electronic, are deployed to assist mariners in safely navigating waters, as well as to prevent accidents and protect the environment. A number of factors are taken into consideration in determining the type of navaid appropriate for use, including but not limited to the geographical area, shoals and other underwater obstructions, current, extent of course alteration, scale of the chart, the need for precision in navigation, and the volume of traffic. Given the danger posed by the shoal marked by buoy NP5, the 40 course alteration (to follow the recommended track) and with no leading lights to assist in navigation, the positioning of buoy NP5 should be such that it will assist the mariner in safely negotiating the bend. As such, the buoy was initially placed in the optimal position marking the NE corner of the shoal when it was established but was subsequently positioned some 160m further west of the optimal position. CHS - Chart Scale and Safety The scale for Bridges Passage on chart No. 5052 was 1:60 000 whereas that on the inset in cancelled chart No4748 was 1:25 000; i.e., the scale had been reduced to about of the original. The Bridges Passage being charted at a smaller scale, and the fact that there are no leading lights for transiting the 300-metre wide Bridges Passage, makes transit of the area difficult and reduces the mariner's ability to accurately plot and closely monitor the vessel's position. As one of the most commonly used methods of navigation is parallel indexing, the larger the scale of the chart, the better the mariner's appreciation of the environment which is essential for the safe navigation of the vessel. On the other hand, the scale issue is mitigated somewhat by the fact that chart No 5052, at a scale of 1:60 000, portrays the whole route on the face of the chart and does not require the transfer of positions to an inset seconds before a critical course alteration. In addition, it provides a continuous coastline to provide the mariner with his points of reference for parallel indexing. CCG and CHS Interlaced Mandates and Safety The CCG and the CHS provide mariners with the tools to safely navigate the vessel. CCG, as the agency responsible for aids to navigation, determines where the buoy is positioned, and CHS, as the agency responsible for chart production, ensures that the buoy is accurately positioned on the chart. This determination has to take into consideration the risk associated with this transit and the most appropriate risk-mitigating options. However, the mariner has no control over the abovementioned criteria. Given this interlaced mandate of CCG and CHS, close coordination between them is essential to help ensure that the scale of the chart and the type and positioning of aids to navigation deployed should be such that a mariner can safely navigate the area. None of the bridge team members was aware that the advertised position of buoy NP5 was not the optimal position. They relied on the buoy to the exclusion of other cues resulting in premature course alteration. The navigating personnel had less than a thorough/complete understanding of the horizontal chart datum, global positioning system (GPS) datum selection mode, and the limitations of the electronic equipment. The Canadian Coast Guard was not aware that the advertised position for the buoy in Notices to Mariners and the List of Lights differed from the optimal position established in 1997.Findings as to Causes and Contributing Factors None of the bridge team members was aware that the advertised position of buoy NP5 was not the optimal position. They relied on the buoy to the exclusion of other cues resulting in premature course alteration. The navigating personnel had less than a thorough/complete understanding of the horizontal chart datum, global positioning system (GPS) datum selection mode, and the limitations of the electronic equipment. The Canadian Coast Guard was not aware that the advertised position for the buoy in Notices to Mariners and the List of Lights differed from the optimal position established in 1997. GPS data was entered on the Buoy Service Report without amplifying information including the datum in use by the receiver; in the Newfoundland region, data input in the SIPA database is not always verified, nor is a graphical/digital system used, which compromises the integrity of the SIPA system. GPS data was entered on the Buoy Service Report without amplifying information including the datum in use by the receiver; in the Newfoundland region, data input in the SIPA database is not always verified, nor is a graphical/digital system used, which compromises the integrity of the SIPA system.Findings As to Risk GPS data was entered on the Buoy Service Report without amplifying information including the datum in use by the receiver; in the Newfoundland region, data input in the SIPA database is not always verified, nor is a graphical/digital system used, which compromises the integrity of the SIPA system. GPS data was entered on the Buoy Service Report without amplifying information including the datum in use by the receiver; in the Newfoundland region, data input in the SIPA database is not always verified, nor is a graphical/digital system used, which compromises the integrity of the SIPA system. The Transport Canada Ship Safety Bulletins were not dispatched to the vessel.Other Findings The Transport Canada Ship Safety Bulletins were not dispatched to the vessel. Safety Action Safety Action Taken Canadian Hydrographic Service and Canadian Coast Guard Following the occurrence, TSB issued Marine Safety Advisory 03/01 to the Department of Fisheries and Oceans which raised concerns that: the datum conversion on new and existing charts may introduce errors in positioning and charting of navigation aids; the adequacy of the level of service with respect to short range navigational aids; and reduction in chart scale together with the reduced details on the chart for Bridges Passage and the removal of the insert may deprive the mariner of some of the cues essential for safe navigation. In response to the concerns, the Canadian Hydrographic Service (CHS) indicated that there is no natural leading line for Bridges Passage, and that the current scale of chart No5052 is adequate without the need for an inset. Further, they indicated that the review of the adequacy of the level of service provided for charts and publications in the Bridges Passage area, and the placement of buoys and other aids to navigation generally, is ongoing. The Canadian Coast Guard (CCG) indicated that the current level of service (Labrador Region) which has been in use in the aids program since 1989, was developed with the involvement of CCG personnel, mariners, scientific researchers and university professors. Further, every aid system is reviewed at least once every five years. Therefore, CCG believes that the current level of service for the aids to navigation program is adequate for the safety of mariners and contributes towards the protection of the environment. The CHS is concerned about the accuracy of the SIPA database and its impact on the data used to update charts. To address this deficiency, the CHS database has been rewritten such that it will not accept anything from the SIPA database that: is referenced on a cancelled chart, or a chart on the wrong datum. Transport Canada The Transportation Safety Board of Canada issued a Marine Safety Advisory (MSA 04/01) to Transport Canada (TC) expressing concern that mariners may not fully understand the need for datum selected on a global positioning system (GPS) to be consistent with the chart datum and that the method of navigation selected may deprive the ship's complement of some of the cues essential for safe navigation. In response, TC indicated that various means that have been used to alert mariners to these concerns, including: Annual Notices to Mariners, Notice 2(7) and Notice 4516, CCG publication entitled GPS/DGPS MADE EASY, edition 2000, International Maritime Organization Safety Navigation Circular 213 of 31 May 2000, entitled Guidance on Chart Datums and Accuracy of Positions on Charts. Additionally, Transport Canada Marine Safety, in consultation with the CCG and the CHS, has developed a Ship Safety Bulletin (SSB No 02/2002), entitled Horizontal Chart Datums and Position Accuracy. The SSB was published on 11February2002 to further raise awareness about this important safety issue of navigation practices and chart datums. Additionally, a notice on chart datums and position accuracy was published in the monthly Notices to Mariners, Edition No4 on 26April2002.